Thank you to An Old Friend, who contributed this topic suggestion.
"Hi moderators, wondering if we could have a discussion on The Practice of Medicine (eg Parson's Sick Law) vs Service Quality and Standards (eg ISO) vs cost and the conflicts they present?
Personally I feel that the delivery of medicine is not the same as the delivery of service in other industries, eg hospitality or airlines.
Secondly, the expectations and cost factors.
For example, while there is always this drive towards "service excellence" in every organization, the quality of the service is different depending on the price you pay for that service. However the management do not look at it that way. They look into every complaint in the same way in every organization. It seems to be left to the customer to decide what his expectations will be (sometimes this can be tempered if he is paying a low price). But it seems that in healthcare, free seems to be the price everyone wants to pay so no luck having any pared down expectations subsidized or not.
Case in point. How do the management of SIA and Singhealth weigh their quality standards? I bet they both want "service quality excellence". I don't see SIA rates being cheap though. Same with ShangRi-La Hotels.
It is extremely difficult if the government does not control the expectations of the people when it comes to subsidized healthcare, and yet want to control cost. The system is extremely taxing on the staff who provide the service. They are sandwiched between trying to give "world class service excellence", but keeping costs low."
I will post my reply first. Perhaps the rest of the panel can add their comments by editing this entry.
I fully agree that healthcare in Singapore has a distinct slant towards service provision, and that patient expectations aren't being managed sufficiently.
Conversations with people from the United States, Canada, Australia and the United Kingdom reveal a very different mentality - they understand the constraints of the public healthcare system based on how much less it costs the consumer.
The ER is a common discussion point - partly because I'm an ER physician. I recall a Canadian couple who recounted an 8-hour wait to consult a doctor about an elderly mother's hip fracture. When I told them an 8-hour wait in our ERs will guarantee a major riot - not to mention a reprimand from MOH, followed by interventional measures - they looked shocked and described this as "grossly unreasonable", especially after I told them we see an average of 400 cases a day, about twice the ER attendances in these countries.
The same goes for Americans and Brits. They know what to expect and usually kick up a fuss only if mismanagement is involved.
One might argue that since the Canadian and UK governments provide free healthcare for its citizens, patients have no cause for complaint.
But Singaporeans also receive substantial subsidies, and have easy access to tertiary hospitals where high-quality medical expertise and technology are readily available ( unlike rural areas in larger nations ).
Even a B2-class patient can be listed for an elective operation within weeks, compared to someone in the UK who waits an average of 12 months for a routine hernia repair or cholecystectomy.
The definition of "service excellence" varies according to the individual. For some, waiting time is a huge factor ( and one of the most important key performance indicators across the board ), while others may pay more attention to, say, the staff's demeanour.
But there's no denying that few subscribe to the idea that "the quality of the service is different depending on the price you pay for that service". In my 10 years within the public sector, I've encountered numerous patients ( and relatives ) who demand a level of service which is better accomodated in a private institution. But when I suggest they seek an opinion at such hospitals, they retort, "Why should I pay more?"
They want immediate scopes, cardiac scans, MRIs, consults with senior specialists. They criticize our "ridiculous policies" of arranging early clinic appointments, even for clearly non-urgent conditions. They start screaming bloody murder when they don't get sent to the ward within 2 hours, even when we explain that the hospital is full and beds can only be emptied when patients are discharged.
Is it because the government isn't controlling the people's expectations? Perhaps, to some extent, this is true, and is reflected by how MOH prioritizes its list of KPIs. After all, waiting times do nothing for a doctor's frazzled psyche, and only serve to pacify and impress the consumer.
The media also plays a part, regularly churning out statistics comparing one hospital / polyclinic with another. Let's not forget the dreaded Forum Page, which every HOD / CEO pores through first thing in the morning, hoping s/he won't see his/her department or institution fingered in a complaint letter which may / may not contain reliable facts.
The evolution of healthcare towards a service industry was probably also accelerated by marketing efforts that trumpet Singapore as THE centre for world-class medical care, including public hospitals in the mix. How much this has affected local perceptions, however, is hard to say.
I wouldn't go so far as to state that "in healthcare, free seems to be the price everyone wants to pay so no luck having any pared down expectations subsidized or not." I do ( occasionally ) meet patients who demonstrate a good understanding of our limitations - and it's no coincidence that many hail from the older age and lower income groups.
Based on personal experience, the majority of those who voice dissatisfaction are the well-educated, more affluent and younger people. I'm especially wary of those who come armed with information from the Internet or "a doctor friend / relative" or "a friend / relative who also has this condition or knows someone who does".
Another contributor to unreasonable expectations? Whether it's deliberate or not, I've had GP referrals asking me to arrange scopes / MRI scans / consults with specialists the very same day the patient comes to the ER.
You can see how this causes problems when the patient thinks I'm trying to pull a fast one, since his/her family physician of XX years, whom s/he trusts whole-heartedly and who can do no wrong, is being contradicted by this idiot of an ER physician.
Anyway, I'm nowhere as good as Angry Doc and Gigamole where in-depth analysis is concerned. Just offering a view from the trenches.
This is not really a 'medical' issue, so I can't claim that my analysis is an accurate one...
There are a few issues being brought up here, from the question of cost and affordability, to quality of "service", and also timeliness of access to care. People want "Better, Faster, Cheaper", and it seems that no one is willing to tell them that they can't have all three.
Good healthcare requires considerable resources, and since resources are limited, healthcare must be rationed. Longtime readers of my blog will know that I used to be an advocate for rationing by needs and not means, but over the years I have changed my views on the topic.
My current views on the topic are set out in the comments section of this earlier post.
Put simply, subsidised healthcare not backed by the moral courage to demand accountability from patients distorts the true value of healthcare and is ultimately destructive to the morale of its providers. We are in the state we are in today because the public thinks they can dictate what resources they wish to consume from the system based solely on the fact that they hold a ballot, and no one tells them otherwise.
Many doctors remain within the public system because they have no choice - they are either bonded or under traineeship - and others remain because the public sector offers them things of value which they cannot obtain in the private sector, such as research or teaching opportunities. No one, however, chooses to stay so they can be told how to do their jobs by laymen. Whatever the reason, as long as we choose to remain in a subsidised healthcare system where laymen's "concerns" are allowed to override our clinical opinions, we are helping to perpetuate it.
I will end by repeating the quote I posted in the earlier thread:
"I observed that in all the discussions that preceded the enslavement of medicine, men discussed everything—except the desires of the doctors. Men considered only the 'welfare' of the patients, with no thought for those who were to provide it. That a doctor should have any right, desire or choice in the matter, was regarded as irrelevant selfishness; his is not to choose, they said, only 'to serve.' That a man who's willing to work under compulsion is too dangerous a brute to entrust with a job in the stockyards—never occurred to those who proposed to help the sick by making life impossible for the healthy.
I have often wondered at the smugness with which people assert their right to enslave me, to control my work, to force my will, to violate my conscience, to stifle my mind—yet what is it that they expect to depend on, when they lie on an operating table under my hands? Their moral code has taught them to believe that it is safe to rely on the virtue of their victims. Well, that is the virtue I have withdrawn. Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it—and still less safe, if he is the sort who doesn't."